CS Form No.
212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)
Bataller
NAME EXTENSION (JR., SR)
FIRST NAME JACQUILINE NENENG
MIDDLE NAME MANLE
3. DATE OF BIRTH
(mm/dd/yyyy) 1/21/1976 16. CITIZENSHIP Filipino
4. PLACE OF BIRTH ATIMONAN, QUEZON If holder of dual citizenship, FILIPINO
please indicate the details.
5. SEX FEMALE
17. RESIDENTIAL ADDRESS 012 PUROK ILANG-ILANG
6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
ZAMORA SUBDV. BRGY. CARIDAD IBABA
Subdivision/Village Barangay
ATIMONAN QUEZON
7. HEIGHT (m) 155
City/Municipality Province
8. WEIGHT (kg) 100 ZIP CODE 4331
18. PERMANENT ADDRESS 012 PUROK ILANG-ILANG
9. BLOOD TYPE AB
House/Block/Lot No. Street
ZAMORA SUBDV. BRGY. CARIDAD IBABA
10. GSIS ID NO. 2005030595
Subdivision/Village Barangay
ATIMONAN QUEZON
11. PAG-IBIG ID NO. 1211-8163-6166
City/Municipality Province
12. PHILHEALTH NO. 08-025034657-7 ZIP CODE 4331
13. SSS NO. 33-2246373-3 19. TELEPHONE NO. N/A
14. TIN NO. 276-335-486 20. MOBILE NO. 09505565233
15. AGENCY EMPLOYEE NO. 5495864 21. E-MAIL ADDRESS (if any) jakiparedes@[Link]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME PAREDES
FIRST NAME LEONARDO
MIDDLE NAME DIVINA
25. MOTHER'S MAIDEN NAME MANLE
SURNAME PAREDES
FIRST NAME SUSAN
MIDDLE NAME LEGAZPI (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST LEVEL/
26. PERIOD OF ATTENDANCE SCHOLARSHIP/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE UNITS YEAR
LEVEL EARNED GRADUATED
ACADEMIC HONORS
(Write in full) (Write in full) RECEIVED
(if not graduated)
From To
3RD HONORABLE
ELEMENTARY ATIMONAN CENTRAL SCHOOL PRIMARY 1982 1989 GRADUATED 1989 MENTION
RESPONSIBLE
SECONDARY
VOCATIONAL /
OUR LADY OF ANGEL ACADEMY HIGH SCHOOL 1989 1993 GRADUATED 1993 STUDENT
CORA DOLOROSA FASHION DESIGN 1995 1995 GRADUATED 1995 N/A
TRADE
COURSE QUEZONIAN EDUCATIONAL COLLEGE OUTSTANDING
COLLEGE
INCORPORATED
BACHELOR OF ELEMENTARY EDUCATION 2000 2004 GRADUATED 2004 STUDENT
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE 09/23/2020
MA
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ LICENSE (if applicable)
RATING DATE OF EXAMINATION /
CES/ CSEE BARANGAY ELIGIBILITY / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) CONFERMENT NUMBER Date of
DRIVER'S LICENSE
Validity
N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
GOV'T SERVICE
28.
INCLUSIVE DATES (mm/dd/yyyy) DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY/ JOB/ PAY
POSITION TITLE GRADE (if applicable)& STATUS OF
(Write in full/Do not MONTHLY SALARY STEP (Format "00-0")/
APPOINTMENT
(Write in full/Do not abbreviate)
abbreviate) INCREMENT
From To (Y/ N)
Department of Education, Malusak National High
06/13/2016 To date Teacher I (SHS) 19620.00 11-1 Provisional Y
School
(Continue on separate sheet if necessary)
SIGNATURE DATE September 23,2020
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29.
NAME & ADDRESS OF ORGANIZATION (Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To
N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
INCLUSIVE DATES OF ATTENDANCE
30. Type of LD
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write in CONDUCTED/ SPONSORED BY
(mm/dd/yyyy) NUMBER OF HOURS ( Managerial/ Supervisory/
full) Technical/etc) (Write in full)
From To
SENIOR HIGH SCHOOL MASS TRAINING OF TEACHERS ON COMMON TOPICS 03/14/2017 03/17/2017 32 TECHNICAL DEPARTMENT OF EDUCATION
REGIONAL MASS TRAINING HIGH SCHOOL TEACHERS FOR TECHNICAL AND LIVELIHOOD EDUCATION 03/05/2017 03/13/2017 72 TECHNICAL DEPARTMENT OF EDUCATION
SCHOOL-BASED IN SERVICE TRAINING 2016 10/24/2016 10/26/2016 24 TECHNICAL DEPARTMENT OF EDUCATION
SCHOOL PARTNERSHIP AND COLLABORATIVE JOURNEY FOR PROFESSIONAL TEACHER 2016 10/27/2016 10/28/2016 16 TECHNICAL DEPARTMENT OF EDUCATION
CLASSROOM-BASED ACTIVITY AND PARENTING SEMINAR 19/19/2016 10/19/2016 8 TECHNICAL DEPARTMENT OF EDUCATION
TEACHER INDUCTION PROGRAM FOR NEWLY APPOINTED TEACHERS 09/15/2016 09/15/2016 8 TECHNICAL DEPARTMENT OF EDUCATION
INSTITUTIONAL AND ENTREPRENURIAL SKILLS DEVELOPMENT TRAINING 05/25/2015 05/29/2015 40 TECHNICAL
NATIONAL FOOD AUTHORITY
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in full)
COOKING N/A N/A
BAKING
(Continue on separate sheet if necessary)
SIGNATURE DATE 09/23/2020
CS FORM 212 (Revised 2017), Page 3 of 4
34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details: ________________________________
NO ________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details: ________________________________
________________________________ No
b. Have you been criminally charged before any court?
If YES, give details: ________________________________
_______________________________
Date Filed: No
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or
tribunal?
If YES, give details: ________________________________
________________________________ No
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from
the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private sector? If YES, give details: ________________________________
Yes
________________________________
Resignation, Went home to Sariaya, Quezon.
38. a. Have you ever been a candidate in a national or local election held within the last year (except Barangay election)?
If YES, give details: No
b. Have you resigned from the government service during the three (3)-month period before the last election to
promote/actively campaign for a national or local candidate? If YES, give details: No
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):
No
40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 7277); and (c) Solo
Parents Welfare Act of 2000 (RA 8972), please answer the following items:
a. Are you a member of any indigenous group?
If YES, please specify: No
b. Are you a person with disability?
If YES, please specify ID No: No
c. Are you a solo parent?
If YES, please specify ID No: No
41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)
NAME ADDRESS TEL. NO. ID picture taken within
the last 6 months
4.5 cm. X 3.5 cm
PRISIA IMELDA P. MIRA VILLA JUANA ATIMONAN,QUEZON 09209683468 (passport size)
Computer generated
[Link] VERDAGUER JR. BRGY MALUSAK ATIMONAN,QUEZON 09108767723 or photocopied picture
is not acceptable
HON. ROLANDO M. MAROON BRGY MALUSAK ATIMONAN,QUEZON 09168326541
42.
PHOTO
Government Issued ID ([Link], GSIS, SSS, PRC, Driver's License, etc.)
PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID:
ID/License/Passport No.:
Signature (Sign inside the box)
Date/Place of Issuance:
Date Accomplished Right Thumbmark
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath
CS FORM 212 (Revised 2017), Page 4 of 4
